Vascular Flashcards
Vascular dx
What is the definition of an abdominal aortic aneurysm?
A dilation of the abdominal aorta to >1.5x its normal diameter, or >3cm
What are the two types of aneurysms?
Saccular
Fusiform
What are three causes of abdominal aneursyms?
Atheroma
Trauma
CTD (Marfans, ED)
What are the presenting symptoms of AAAs?
Majority are asymptomatic
Can complain of pain/pulsation in the back
What are the risk factors for AAAs?
Male CTD Hypertension Hypercholesterolaemia Smoking
What is the mortality rate of ruptured AAAs?
90%
What is the presentation of a ruptured AAA?
Severe abdominal pain, radiating to the back
What can be found on examining a Pt with AAA?
Retroperitoneal bleeding -> Grey Turner’s/Cullen’s
Hypovolaemic shock -> low BP/high HR
What is the screening criteria for AAAs?
Males >65yrs
What is the modality of investigation for AAAs?
Ultrasound scan
What is the management plan for small AAAs (3.5-4.4cm)?
Follow up scan in 1 year Conservative management -smoking, exercise, weight loss Medical management -statins, aspirin, BP management
What is the management plan for medium AAAs (4.5-5.4cm)?
Follow up scan in 3 months Conservative management -smoking, exercise, weight loss Medical management -statins, aspirin, BP management
What is the management plan for large AAAs (5.5cm+)?
Open aortic surgery
Endovascular repair
What are the cons of open aortic surgery?
Longer recovery time hence done on young patients
What are the cons of endovascular repair?
Less peri-op mortality but greater risk of needing more procedures
What is the definition of an aortic dissection?
A tear in the tunica intima causing blood accumulation between the inner and outer tunica media.
What is the Stanford Classification of aortic dissections?
Type A- ascending aorta tear
Type B- descending aorta tear (after the left subclavian)
What are the risk factors of an aortic dissection?
HTN Atherosclerosis CTD Iatrogenic (angiography/plasty) Congenital- coarctation Cocaine
What are the presenting symptoms of aortic dissections?
Sudden central tearing pain in the back
What can happen if the tear affects the carotids?
Hemiparesis
Blackouts
What can happen if the tear affects the coronary arteries?
Angina
MI
What can happen if the tear affects the renal arteries?
AKI
Renal failure
What can happen if the tear affects the coeliac trunk?
Abdominal pain
What can you find on examination of a Pt with aortic dissection?
Tachycardia BP difference of >20mmHg in upper limbs Radio-radial delay Wide pulse pressure Murmur below scapulae
What are the two key signs of aortic insufficiency?
Collapsing pulse
Early diastolic murmur
(Aortic regurgitation)
What bloods investigations would you do for aortic dissection and why?
FBC, U&Es- renal damage
Xmatch- 10 units of blood for hypotension
Cardiac enzymes- heart attack
What would you see in a CXR of a Pt with aortic dissection?
Widened mediastinum
Visible aortic notch
Why would you do a CT angiography of a Pt with aortic dissection?
Visualise the location of the dissection
Which is the best diagnostic intervention for aortic dissection?
CT angio
A 69 year old man with a background of hypertension complained of flank pain all day at work. He then has sudden onset abdominal pain that radiates to his back and groin. He arrives in an ambulance unconscious. The doctor notes Grey Turner’s and Cullen’s signs. What is the most likely diagnosis?
A. Renal colic
B. Myocardial ischaemia
C. Ruptured AAA
D. Pancreatitis
C. Ruptured AAA
A 65 year old gentleman is coming in for screening for a AAA following a letter received in the post. What modality would be used as a screening tool?
A. Abdominal ultrasound
B. Abdominal CT
C. Abdominal X-ray
D. Doppler ultrasound
A. Abdominal Ultrasound
A 65 year old gentleman with a known AAA (last measured 5.2 cm) comes in complaining of severe abdominal pain. What investigation would you use to assess if it has ruptured?
A. Abdominal ultrasound
B. Abdominal CT
C. Abdominal X-ray
D. Doppler ultrasound
B. Abdominal CT
A 70 year old gentleman with known hypertension presents to A&E with tearing chest pain, radiating to the back. His CXR shows a widened mediastinum. What is the most likely diagnosis?
A. Aortic dissection
B. STEMI
C. Tietze’s syndrome
D. Costochondritis
A. Aortic dissection
Which of the following examination findings is not consistent with an aortic dissection?
A. BP 100/40
B. Ejection systolic murmur
C. Collapsing pulse
D. Radio-radio delay
B. Ejection systolic murmur
What is intermittent claudication?
Cramping muscular pain in the calf, thigh, or buttocks, precipitated by exercise and alleviated by rest
What are the risk factors for intermittent claudication?
Smoking
Diabetes mellitus
Hypertension
Cholesterol
What are the signs of intermittent claudication?
Weak peripheral pulses Punched out ulcers Hair loss Cyanosis Brittle toes Beurger's angle <20
What is Leriche’s syndrome?
Narrowing of the abdominal aorta as it bifurcates into the common iliacs
What is the triad seen in Leriche’s syndrome?
Bilateral claudication
Erectile dysfunction
Weak femoral pulses
What is the triad of critical limb ischaemia?
Rest pain (Alleviated by standing)
Arterial ulcers
Gangrene
What is the prognosis for intermittent claudication?
80% chance of improvement
5% intervention
1% amputation
15% dead in 5 years
What is the prognosis for critical limb ischaemia?
90% intervention
25% amputation
50% dead in 5 years
What are the different indices (levels) of ABPI?
> 0.95- normal
0.5-0.95-claudication
0.3-0.5- rest pain
<0.3- critical ischaemia
What can cause false negatives in ABPIs?
Calcification of vessels
What other investigations can be done for claudication?
Doppler USS
Magnetic resonance angiography
What is acute limb ischaemia?
Sudden lack of blood flow to a limb
What are the two causes of acute limb ischaemia?
Thrombus- due to peripheral arterial disease
Embolus- from the heart
What are the six P’s of acute limb ischaemia?
Pain Pallor Pulselessness Perishingly cold Paraesthesia Paralysis
What is the classification of acute limb ischaemia?
Viable
-no neuro signs + audible Doppler
Threatened
-sensory loss + tense calf + no audible Doppler
Dead
-complete neurological deficit, fixed mottling
A 65 year old lady with known CVD presents to the GP with pain in her legs. She finds the pain comes on when she is walking to the shops, but is relieved by rest. She has a 40 pack year smoking history. What is the most likely diagnosis?
A. Acute limb ischaemia
B. Deep vein thrombosis
C. Varicose veins
D. Peripheral arterial disease
D. Peripheral arterial disease
A 60 year old male with known atrial fibrillation presents to A&E with a sudden onset of a painful, cold leg. The doctor is unable to feel peripheral pulses, and upon examination notes a loss of sensation and paralysis. A venous Doppler is inaudible. What is the definitive management?
A. Embolectomy
B. Watch and wait
C. Angioplasty
D. Amputation
D. Amputation
A 69 year old heavy smoker complains of pain in his leg when he walks to the bus stop. On examination of his leg, you see shiny skin, patchy hair, weak pulses and brittle toenails. What would be the first line investigation?
A. Angiography
B. Doppler ultrasound
C. Magnetic resonance angiography
D. ABPI
D. ABPI
What is a DVT?
Formation of a clot in the deep veins
What is Virchow’s triad?
Venous stasis
Endothelial damage
Hypercoagulability
What are the inherited risk factors for DVTs?
Antithrombin deficiency
Protein C/S deficiency
Antiphospholipid syndrome
What are the acquired risk factors for DVTs?
Age Pregnancy Trauma Surgery Immobility Previous DVT Cancer Oestrogen
What is the presentation of a DVT?
50% asymptomatic
Leg swelling
Calf tenderness
Erythema
What is found on examination of a DVT?
Pitting oedema
Calf warmth
Calf swelling >3cm difference
Prominent superficial veins
What is the scoring used for DVTs?
Well’s score
If the Well’s score is >=2 what investigation do you do?
Leg vein USS
If the Well’s score is >=2 and the USS is -ve what investigation do you do, and what would you do if THAT finding was positive?
D-dimer
If D-dimer is positive, repeat USS in 6-8 days
If the Well’s score is <2 what investigation do you do, and what would you do if THAT finding was positive?
D-dimer
If D-dimer is positive, perform USS
What management would you provide for a Pt with a DVT?
LMWH for 5 days
Warfarin within 24h for at least 3 months
When would you consider thrombolytic therapy?
If the symptoms have been less than two weeks, the Pt is well, has a good life expectancy and at a low risk of bleeding
What surgical procedure can be offered for a DVT?
Thrombectomy
What preventative management can be offered for a DVT?
Stop OCP 4 weeks before surgery
Compression stockings
LMWH for high risk Pts
Why is LMWH given with warfarin?
Warfarin inhibits F2,7,9,10, Protein C and S
Hence it has an initial pro-coagulative phase
LMWH is given to counteract this
A 38 year old lady presents with swelling in her leg, and associated calf tenderness. She has been taking the OCP for several years. What is the best management for this patient?
A. Warfarin + LMWH B. Warfarin C. Aspirin D. LMWH + Aspirin E. LMWH
A. Warfarin + LMWH
A 72 year old gentleman is complaining of pain in his right leg. He is 8 days post operative for a tibia/fibula fracture repair. What is the minimum amount of time the patient must be anticoagulated for?
A. 3 months
B. 6 months
C. 1 year
D. Lifelong
A. 3 months
A 32 year old woman on the OCP complains of pain in her calf for one day. She does not have any chest pain or shortness of breath. The nurse tells you that the A&E doctors assessed the patient, who scored 2 although she cannot remember the name of the score. What is the most appropriate initial investigation?
A. D-Dimer
B. MRA
C. Leg Vein USS
D. ABPI
C. Leg Vein USS
What is the cause of an arterial/ischaemic ulcer?
Lack of blood flow causing ischaemia, commonly due to PAD
What are the characteristics of an arterial/ischaemic ulcer?
Between toes/lateral aspect of foot and ankle Punched out appearance Very painful Gangrene/necrosis Minimal exudate Surrounding skin- hairless, cold, shiny
What is the cause of a venous ulcer?
Inadequate valvular function causes leakage of blood and protein into extravascular spaces.
Build up of fibrinogen and fibrin causes reduced O2 delivery
Leukocyte accumulation releases proteolytic enzymes and ROS
What are the characteristics of a venous ulcer?
Located in the "gaiter" region Shallow, irregular Usually painless Wet Surrounding skin- oedematous, lipodermatosclerosis, haemosiderin deposition
What is the cause of a neuropathic ulcer?
Diabetics with peripheral neuropathy
Loss of pain sensation in blisters/pressure injuries
What are the characteristics of a neuropathic ulcer?
Ulcers on the plantar aspect Even wound margins Loss of pain sensation Deep ulcer Calloused skin May be infected Palpable pulses and warm foot
A 75 year old woman with long standing hypertension has had progressive swelling of her legs over the last 3 months. She has consulted her GP because she has developed an ulcer on the anterior aspect of the right shin which weeps serous fluid profusely. What is the cause of the ulcer?
A. Arterial
B. Venous
C. Neuropathic
D. Rheumatoid Arthritis
B. Venous
A 62 year old diabetic woman shows you an ulcer on the bottom of her foot. It has a little stone lodged in it, which she hasn’t noticed. On neurological examination, she has no peripheral sensation of light touch up to her mid-foot. What is the cause of the ulcer?
A. Arterial
B. Venous
C. Neuropathic
D. Trauma
C. Neuropathic
A 78 year old obese woman presents with an ulcer on the top of her foot and one between her toes. They haven’t healed in two months. They are quite small, look punched out and yellow. She complains her feet are always cold and has a history of coronary artery disease.
A. Arterial
B. Venous
C. Neuropathic
D. Trauma
A. Arterial
A 45 year old lady presents with a 4 cm chronic ulcer on the medial aspect of the lower leg. She has a history of pain in the calf on walking. The skin around the ulcer is brown and heavily indurated.
A. Arterial
B. Venous
C. Neuropathic
D. Trauma
B. Venous
What is the cause of varicose veins?
Valvular insufficiency
What are the risk factors of varicose veins?
Obesity
Pregnancy
OCP
Family history
What are the presentations of varicose veins?
Pain Unsightly legs Cramps Tingling Restless leg
What are the examination findings of varicose veins?
Oedema Eczema Ulcers Phlebitis Atrophie blanche Lipodermatosclerosis
What is the management of varicose veins?
Endothermal ablation
US-guided foam scleropathy
Surgery
